PEBB Medical And Dental Enrollment Form Self Pay Participants 2008 Plan Year Instructions www.oregon.gov/DAS/PEBB
Complete this form to enroll for medical and dental coverage through the Public Employees’ Benefit Board (PEBB) or to make a change in coverage during Open Enrollment. SECTION A – PARTICIPANT INFORMATION • Complete each item in this section. • Continuing participation: check the Open Enrollment box.
SECTION B – MEDICAL AND DENTAL PLAN ELECTIONS (You must have medical to enroll in dental) • Check the box for the plan(s) you are selecting. B.1: Medical: Note: Blind Business Enterprise Participants: medical plan enrollment only. B.2: Dental: . SECTION C – DEPENDENT INFORMATION AND PLAN SELECTION • Complete each item in this section. • List all eligible dependents. Dependents not listed will not be covered. • If you are adding an individual by PEBB Affidavit of Domestic Partnership or PEBB Affidavit of Dependency you must submit the appropriate affidavit within 5 business days of this enrollment election. If not, coverage for the individual by affidavit will terminate retroactive to the effective date. • Additional information and forms are available from BenefitHelp Solutions, the PEBB web site, and in the 2008 PEBB Benefits Handbook. SECTION D – DEPENDENT CHILDREN CERTIFICATION AND MEDICARE INFORMATION • Check the appropriate box. D.1: You must certify that your dependent children between the ages of 19 up to 24 continue to meet the PEBB eligibility requirements. If you do not certify, your dependent’s enrollments will not be processed. D.2: You must check the appropriate box when adding a Domestic Partner. D.3: You must attach a copy of the Medicare card for each individual enrolled in Medicare. SECTION E – PARTICIPANT SIGNATURE AND AUTHORIZATION • Read this section carefully. Sign and date the form. • Make a copy for your records and submit to: BenefitHelp Solutions (BHS) PO Box 67240 Portland, OR 97268-1240 Portland (503) 765-3581 Toll-free (800) 556-3137
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Medical And Dental Enrollment Form Self Pay Participants 2008 Plan Year SECTION A - PARTICIPANT INFORMATION
New Participant—provide the date you became eligibile: LAST DATE OF BIRTH (MM-DD-YYYY) RESIDENCE ADDRESS New Address OLCC Agent Post Docs/J1 Visa Blind Business Enterprise Open Enrollment Foster Parent – you must attach a copy of the Foster Parent Certificate FIRST MI ID NUMBER (SSN, University ID, Benefit Number)
GENDER CITY COUNTY
FEMALE STATE HOME PHONE
MALE ZIP
MAILING ADDRESS (if different from above)
New Address
AGENCY
E-MAIL
SECTION B - MEDICAL AND DENTAL PLAN ELECTIONS (Must have Medical Coverage to enroll in a Dental Plan):
B-1 Medical (select one):
No Coverage Kaiser HMO Kaiser Added Choice Providence Choice PPO Regence BCBSO PPO Samaritan Select PPO
B-2 Dental (select one): Not all participants are eligible for dental.
Please see instructions. No Coverage Kaiser Permanente Willamette ODS Preferred Option ODS Traditional
SECTION C - DEPENDENT INFORMATION AND PLAN SELECTION
List all eligible dependents you wish to cover and check plan selections. If covering a domestic partner, partner’s children, or dependent by affidavit, a completed affidavit must be attached or on file. Relationship Key: SP=Spouse, DP=Domestic Partner, CH=Employee and/or Spouse’s child,
DP CH=Domestic Partner’s child, AFF CH=Child by Affidavit
Last Name First Name MI ID Number Birth Date Relationship Gender F M Prior PEBB Member Y N Plan Med Dental
SECTION D – DEPENDENT CHILDREN CERTIFICATION AND MEDICARE INFORMATION
D.1 Dependent certification –see instructions.
D.2 Domestic Partner – see instructions. Detailed eligibity information is availabe at www.oregon.gov/DAS/PEBB or in the 2008 PEBB Handbook. I certify that all my dependent children, between the ages of 19 – 24 meet the eligiblity requirements for enrollment in the PEBB plans. Domestic Partner by PEBB Affidavit of Domestic Partnership Domestic Partner by Certificate of Registered Domestic Partnership I am covered by Medicare My dependent(s) is covered by Medicare
D.3 Medicare Information – see instructions.
SECTION E - PARTICIPANT SIGNATURE AND AUTHORIZATION
I declare that the individuals listed on the enrollment form and I are eligible for the coverage requested. I understand the benefit elections made on this application are in effect for as long as I continue to meet PEBB’s eligibility requirements, or until I elect to change them subject to the provisions of PEBB’s plan. I have read the benefit materials and I understand the limitations and qualifications of the PEBB benefits program. If necessary, I authorize premium payments deducted from my pay, unless I self pay premiums. If I self-pay the premiums, I agree to submit monthly payments by the date specified, or my coverage will terminate. A person who knowingly makes a false statement in connection with an application for any benefit may be subject to imprisonment and fines. Additionally, knowingly making a false statement may subject a person to termination of enrollment, denial of future enrollment, or civil damages. This form supersedes all forms and submissions I previously made for PEBB coverage. I hereby declare that the above statements are true to the best of my knowledge and belief, and I understand that they are subject to penalty for perjury.
________________________________________________________ Participant Signature
“PEBB Use Only” Approved by PEBB (initials): Date: Effective date:
___________________________________________ Date
PDB updated by (initials)
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